Neuropsychological alterations and neuroradiological findings in patients with post-traumatic concussion: Results of a pilot study. / Alteraciones neuropsicológicas y hallazgos neurorradiológicos en pacientes con conmoción cerebral postraumática. Resultados de un estudio piloto.

INTRODUCTION: Mild traumatic brain injury (mTBI) has traditionally been considered to cause no significant brain damage since symptoms spontaneously remit after a few days. However, this idea is facing increasing scrutiny. The purpose of this study is to demonstrate the presence of early cognitive alterations in a series of patients with mTBI and to link these findings to different markers of brain damage. METHODS: We conducted a prospective study of a consecutive series of patients with mTBI who were evaluated over a 12-month period. Forty-one (3.7%) of the 1144 included patients had experienced a concussion. Patients underwent a routine clinical evaluation and a brain computed tomography (CT) scan, and were also administered a standardised test for post-concussion symptoms within the first 24hours of mTBI and also 1 to 2 weeks later. The second assessment also included a neuropsychological test battery. The results of these studies were compared to those of a control group of 28 healthy volunteers with similar characteristics. Twenty patients underwent an MRI scan. RESULTS: Verbal memory and learning were the cognitive functions most affected by mTBI. Seven out of the 20 patients with normal CT findings displayed structural alterations on MR images, which were compatible with diffuse axonal injury in 2 cases. CONCLUSIONS: Results from this pilot study suggest that early cognitive alterations and structural brain lesions affect a considerable percentage of patients with post-concussion syndrome following mTBI.

Brainstem auditory and somatosensory evoked potentials: a methodological study to evaluate the reproducibility of two devices.

We aimed to determine whether statistical significant differences exist between the sets of results obtained from two devices used in our department for measuring brainstem auditory evoked potentials (BAEPs) and somatosensory evoked potentials (SEPs). We obtained BAEP and median and posterior tibial nerve SEP values bilaterally in ten healthy subjects. The tests were performed on the same subject using two devices consecutively. The equipment consisted of a Nicolet Viking-IV (Nicolet, Madison, WI, USA) and a Viking Select (Viasys Healthcare, Madison, WI, USA), and the same recording electrodes and stimulator (auditory and electrical) were used without modifying any postural position of the subject. The stimuli and recording parameters were the same for both devices. We obtained 20 sets of data for each type of test. The Bland­Altman plots as well as the one-sample t-test or Wilcoxon signed rank test were used to compare data between the two groups of data sets. We found no significant differences between the sets of values obtained with the two devices. Our analysis indicates that the two devices are equal in recording all different variables of BAEP and SEP, which allows us to combine the BAEP and SEP data obtained from the two devices for follow-up studies involving quantitative statistical methods. This study received institutional approval (protocol number PRAG-154/2013).

Sleep disturbance: a forgotten syndrome in patients with Chiari I malformation.

INTRODUCTION: Chiari type I malformation (CM-I) is characterised by caudal ectopia of the cerebellar tonsils through the foramen magnum. This is associated with brain stem, high spinal cord, and cranial nerve compression phenomena. The most frequent symptoms are occipital headaches and dizziness. Less well-known symptoms are sleep disorders and nocturnal respiratory abnormalities. SOURCES: MEDLINE and information from patients evaluated at the Neurosurgery and Clinical Neurophysiology Departments at Hospital Universitario Vall d'Hebron. DEVELOPMENT: Review article based on data obtained from MEDLINE articles since 1966, using combinations of the following keywords: «Chiari malformation¼ or «Arnold-Chiari malformation¼ and «sleep apnea¼ or «sleep disorders¼. CONCLUSIONS: CM-I patients show a higher prevalence of sleep disorders than that observed in the general population. Some studies report a 50% prevalence of sleep apnea-hypopnea syndrome (SAHS), probably associated with sudden death in some cases. These results support analysing sleep respiratory parameters in theses patients. Identifying SAHS symptoms may help optimise treatment, thereby improving quality of life and prognosis.

[Cortical spreading depolarization phenomena in patients with traumatic and ischemic brain injuries. Results of a pilot study]. / Fenómenos de despolarización cortical propagada en los pacientes con lesiones cerebrales traumáticas e isquémicas. Resultados de un estudio piloto.

OBJECTIVES: To determine the frequency and duration of cortical spreading depolarization (CSD) and CSD-like episodes in patients with traumatic brain injury (TBI) and malignant middle cerebral artery infarction (MMCAI) requiring craniotomy. DESIGN: A descriptive observational study was carried out during 19 months. SETTING: Neurocritical patients. PATIENTS: Sixteen patients were included: 9 with MMCAI and 7 with moderate or severe TBI, requiring surgical treatment. INTERVENTIONS: A 6-electrode subdural electrocorticographic (ECoG) strip was placed onto the perilesional cortex. MAIN VARIABLES OF INTEREST: An analysis was made of the time profile and the number and duration of CSD and CSD-like episodes recorded from the ECoGs. RESULTS: Of the 16 patients enrolled, 9 presented episodes of CSD or CSD-like phenomena, of highly variable frequency and duration. CONCLUSIONS: Episodes of CSD and CSD-like phenomena are frequently detected in the ischemic penumbra and/or traumatic cortical regions of patients with MMCAI who require decompressive craniectomy or of patients with contusional TBI.

Infrared pupillometry. Basic principles and their application in the non-invasive monitoring of neurocritical patients.

INTRODUCTION: Pupil assessment is a fundamental part of the neurological examination. Size and reactivity to light of each pupil should be recorded periodically since changes in these parameters may represent the only detectable sign of neurological deterioration in some patients. However, there is great intraobserver and interobserver variability in pupil examination due to the influence of many factors, such as the difference in ambient lighting, the visual acuity and experience of the examiner, the intensity of the luminous stimulus, and the method used to direct this stimulus. In recent years, digital cameras have incorporated infrared devices allowing the development of user-friendly portable devices that permit repeated, non-invasive examinations of pupil size and its reactivity to light with an objective, accessible and inexpensive method. DEVELOPMENT: The purpose of this review is to describe the fundamentals of infrared pupillometry and discuss potential applications in the monitoring of neurocritical patients. We also present some recommendations in the routine assessment of pupils in neurocritical patients. CONCLUSIONS: The possibility of evaluating the changes in pupil reactivity in an early, objective and almost continuous way provides a new non-invasive monitoring method. This method could improve the predictive factor of neurological deterioration and the bedside monitoring of the neurological state of the patient, avoiding unnecessary examinations and enabling early therapeutic intervention.

Proteomic analysis of cerebrospinal fluid from obese women with idiopathic intracranial hypertension: a new approach for identifying new candidates in the pathogenesis of obesity.

Body weight control is tightly regulated in the hypothalamus. The inaccessibility of human brain tissue can be partially solved by using cerebrospinal fluid (CSF) as a tool for assessing the central nervous system's production of orexigen and anorexigen factors. Using proteomic analysis, the present study investigated the differentially displayed proteins in human CSF from obese and non-obese subjects. We designed a case-control study conducted in a reference hospital where eight obese (cases) and eight non-obese (controls) women with idiopathic intracranial hypertension were included. Intracranial hypertension was normalised through the placement of a ventriculo- or lumboperitoneal shunt in the 12 months before their inclusion in the study. Isotope-coded protein label (for proteins > 10 kDa) and label-free liquid chromatography (for proteins < 10 kDa) associated with mass spectrometry analysis were used. Eighteen differentially expressed proteins were identified. Many of them fall into three main groups: inflammation (osteopontin, fibrinogen γ and ß chain, α1 acid glycoprotein 2 and haptoglobin), neuroendocrine mediators (neurosecretory protein VGF, neuroendocrine protein 7B2, chromogranin-A and chromogranin B), and brain plasticity (testican-1, isoform 10 of fibronectin, galectin-3 binding protein and metalloproteinase inhibitor type 2). The differential production of osteopontin, neurosecretory protein VGF, chromogranin-A and fibrinogen γ chain was further confirmed by either enzyme-linked immunosorbent assay or western blotting. In conclusion, we have identified potential candidates that could be involved in the pathogenesis of obesity. Further studies aiming to investigating the precise role of these proteins in the pathogenesis of obesity and their potential therapeutic implications are needed.

[Is lactate a good indicator of brain tissue hypoxia in the acute phase of traumatic brain injury? Results of a pilot study in 21 patients]. / ¿Es el lactato un buen indicador de hipoxia tisular? Resultados de un estudio piloto en 21 pacientes con un traumatismo craneoencefálico.

UNLABELLED: Lactate and the lactate-pyruvate index (LPI) are two hypoxia markers widely used to detect brain tissue hypoxia in patients with acute traumatic brain injury. These two markers have a more complex behavior than expected as they can be abnormally high in circumstances with no detectable brain hypoxia. This condition must be considered in the differential diagnosis because it also reflects an alteration of brain energy metabolism. OBJECTIVES: 1. To describe cerebral energy metabolism characteristics observed in the acute phase of traumatic brain injury (TBI) based on two traditional indicators of anaerobic metabolism: lactate and LPI, 2. To determine the concordance between these two biomarkers in order to classify the incidence of anaerobic metabolism and 3. To classify the different types of metabolic abnormalities found in patients with moderate and severe TBI using both lactate and LPI. MATERIALS AND METHODS: Twenty-one patients were randomly selected from a cohort of moderate or severe TBI patients admitted to the neurotraumatology intensive care unit. All of them who underwent both cerebral microdialysis and brain tissue oxygen monitoring (PtiO(2)). We analyzed the levels of lactate and the LPI for every microvial within the first 96 hours after head trauma. These data were correlated with PtiO(2) values. RESULTS: Lactate levels and the LPI were respectively increased during 49.5% and 38.4% of the monitoring time. The incidence and behavior of high levels of both markers were extremely heterogeneous. The concordance between these two biomarkers to determine episodes of dysfunctional metabolism was very weak (Kappa Index=0.29; IC 95%: 0.24-0.34). Based on the levels of lactate and the LPI, we defined four metabolic patterns: I: L>2.5 mmol/L and LPR>25; II: L>2.5 mmol/L and LPR< or = 25; III: L< or = 2.5 mmol/L and LPR< or = 25; IV: L< or = 2.5 mmol/L and LPR>25). In more than 80% of cases in which lactate or LPI were increased, PtiO(2) values were within the normal range (PtiO(2)> 15 mmHg). CONCLUSIONS: Increased lactate and LPI were frequent findings after acute TBI and in most cases they were not related to episodes of brain tissue hypoxia. Furthermore, the concordance between both biomarkers to classify metabolic dysfunction was weak. LPI and lactate should not be used indistinctly in everyday clinical practice because of the weak correlation between these two markers, the difficulty in their interpretation and the heterogeneous and complex nature of the pathophysiology. Other differential diagnoses apart from tissue hypoxia should always be considered when high lactate and/or LPI are detected in the acute injured brain.

[Cognitive event-related brain potentials (P300) in patients with normal pressure hydrocephalus. Results of a prospective study]. / Potenciales evocados cognitivos (P300) en pacientes con hidrocefalia de presión normal.

OBJECTIVE: To determine the response to cognitive event-related potentials (P300) in patients with normal-pressure hydrocephalus (NPH) and their relationship with clinical and cognitive status before and after shunt surgery. METHODS: We performed a prospective study in a series of 26 patients with NPH who underwent clinical and cognitive assessment before surgery and 6 months afterwards. Visual P300 potentials obtained before and after treatment were also compared with those obtained in 18 healthy volunteers. RESULTS: Before shunting, the P300 wave was detected in 11 (42.3%) NPH patients, compared with the 18 (100%) volunteers. Six months after shunting, the P300 wave was found in 20 (76.9%) NPH patients. P300 latency was significantly longer in NPH patients than in the control group before surgery, but not at 6 months after surgery. No significant differences in neuropsychological studies or in the level of dependence for daily life activities were found between the subgroups of NPH patients with and without pre-surgical P300 waves, or between changes in P300 parameters and clinical and cognitive changes. CONCLUSIONS: The P300 wave was delayed or undetectable in a substantial percentage of patients with NPH before surgery. These alterations can be reversed by shunting. P300 analysis and neuropsychological tests could be complementary measures to evaluate functional status in patients with NPH.

[High-resolution microdialysis. methodological issues and application to the study of inflammatory brain response]. / Microdiálisis de alta resolución. Aspectos metodológicos y aplicación al estudio de larespuesta inflamatoria cerebral.

Cerebral microdialysis is a tool that provides very relevant information in the metabolic monitoring of brain injured patients. It is a particularly effective technique for the detection and analysis of small molecules, given that the pores of the dialysis membrane act as a barrier to restrict the transport of larger species, such as proteins and other macromolecules. The recent availability of microdialysis catheters with membrane pores of larger size, termed "high resolution" catheters, would widen the spectrum of molecules detectable in the dialisate. However, there are technical complications related to the use of these catheters for such purposes, and therefore, this potential capacity for the recovery of proteins needs to be validated, in order to begin its application as a tool in studies of proteomics associated with brain injuries. The following review depicts the basic principles of microdialysis, and describes some of the issues involved in the recovery of molecules in the dialisate, including the physical properties of the dialysis membrane and of the molecules of interest.

[Cognitive impairment in normal pressure hydrocephalus (NPH). A proposal for clinical evaluation protocol]. / Alteraciones cognitivas en pacientes con hidrocefalia crónica del adulto ("normotensiva"). Propuesta de un protocolo para su evaluación clínica.

Normal pressure hydrocephalus (NPH) is characterized by gait disturbance, urinary incontinence and dementia, and is associated with variable ventricular enlargement. The most accepted treatment of NPH is the placement of a cerebrospinal fluid shunt. Owing to the characteristics of the patients and the invasive nature of the surgical treatment, it is fundamental to detect those patients who could obtain a greater benefit from the treatment. Neuropsychological assessment of these patients could significantly contribute to a better diagnosis of NPH, determining a cognitive deterioration profile for these patients, allowing the assessment of treatment efficacy and helping to detect other additional causes of dementia. The aim of this study is to describe the cognitive deterioration profile of NPH patients and to present the clinical, functional and neuropsychological assessment protocol used in our hospital.

Neonatal Alexander disease: MR imaging prenatal diagnosis.

SUMMARY: Alexander disease (AD) is a rare neurodegenerative disorder characterized by megalencephaly, leukoencephalopathy, and Rosenthal fibers within astrocytes. This report describes the case of a female patient with sonography-detected ventriculomegaly at 32 weeks' gestation and distinctive MR imaging features at 33 and 36 weeks' gestation, at birth, and at 2 months of age, which led to the suggested diagnosis of Alexander disease. Molecular analysis confirmed a missense mutation in the GFAP gene. The literature contains little information on the fetal MR imaging findings that may allow prenatal diagnosis of AD.

[A proposal of a neuropsychological and quality of life assessment protocol in patients with malignant middle cerebral artery infarction]. / Propuesta de un protocolo de valoración neuropsicológica y de calidad de vida en pacientes que han sufrido un infarto maligno de la arteria cerebral media.

Malignant middle cerebral artery infarction (MMCAI) refers to an infarction type normally accompanied by massive cerebral edema, and associated with a high mortality rate under conventional therapeutic measures. Both moderate hypothermia and decompressive hemicraniectomy have been shown to significantly improve survival rate, although controversy still persists regarding the criteria for the selection of patients that could benefit from this type of treatment, and whether application of these measures is justified given the residual sequelae. In our centre, both measures are being applied simultaneously for the first time in humans. The present work is a literature review on the results of moderate hypothermia application and decompressive surgical techniques in patients suffering from MMCAI. We also introduce our management scheme for handling these patients in our centre, and propose a final result evaluation protocol that is easily applied in a clinical setting. This protocol includes an evaluation of patients with ischemic lesions specific for the right or left hemisphere, and allows for the description of specific neuropsychological sequelae and their repercussions on patients' quality of life.

Brain contusions induce a strong local overexpression of MMP-9. Results of a pilot study.

BACKGROUND: Brain contusions are inflammatory evolutive lesions that induce intracranial pressure increase and edema, contributing to neurological outcome. Matrix metalloproteinases (MMPs) 2 and 9 can degrade the majority of the extracellular matrix components, and are implicated in blood-brain barrier disruption and edema formation. The aim of this study was to investigate MMP-2 and MMP-9 profiles in human brain contusions using zymography. METHODS: A prospective study was conducted in 20 traumatic brain injury patients where contusion brain tissue was resected. Brain tissues from lobectomies were used as controls. Brain homogenates were analysed by gelatin zymography and in situ zimography was performed to confirm results, on one control and one brain contusion tissue sample. FINDINGS: MMP-2 and MMP-9 levels were higher in brain contusions when compared to controls. MMP-9 was high during the first 24 hours and at 48 to 96 hours, whereas MMP-2 was slightly high at 24 to 96 hours. In situ zymography confirmed gelatin zymography results. A relation between outcome and MMP-9 levels was found; MMP-9 levels were higher in patients with worst outcome. CONCLUSIONS: Our results indicate strong time-dependent gelatinase expression primarily from MMP-9, suggesting that the inflammatory response induced by focal lesions should be considered as a new therapeutic target.

Influence of APOE polymorphism on cognitive and behavioural outcome in moderate and severe traumatic brain injury.

AIM: To analyse the influence of apolipoprotein (APOE) epsilon4 status on the cognitive and behavioural functions usually impaired after moderate and severe traumatic brain injury (TBI). METHODS: In all, 77 patients with TBI selected from 140 consecutive admissions were genotyped for APOE. Each patient was subjected to neuropsychological and neurobehavioural assessment at least 6 months after injury. RESULTS: Performance of participants carrying the epsilon4 allele was notably worse on verbal memory (Auditory Verbal Learning Test), motor speed, fine motor coordination, visual scanning, attention and mental flexibility (Grooved Pegboard, Symbol Digit Modalities Test and part B of the Trail Making Test) and showed considerably more neurobehavioural disturbances (Neurobehavioral Rating Scale-Revised) than the group without the epsilon4 allele. CONCLUSIONS: In particular, performance on neuropsychological tasks that are presumed to be related to temporal lobe, frontal lobe and white matter integrity is worse in patients with the APOE epsilon4 allele than in those without it. More neurobehavioural disturbances are observed in APOE epsilon4 carriers than in APOE epsilon2 and epsilon3 carriers.

[Recent advances in regional cerebral monitoring in the neurocritical patient: brain tissue oxygen pressure monitoring, cerebral microdialysis and near-infrared spectroscopy]. / Actualizaciones en los métados de monitorización cerebral regional en los pacientes neurocríticos: presión tisular de oxígeno, microdiálisis cerebral y técnicas de espectroscopía por infrarrojos.

The long term outcome of head-injured patients depends not only on the primary brain lesions but also to a large extent on the secondary lesions. The diagnosis of many secondary lesions, and specially that of brain ischemia, is based on simultaneous monitoring of several intracranial and systemic variables. Continuous intracranial pressure (ICP) monitoring is currently considered indispensable in the management of all patients with a severe head injury and intracranial lesions. However, the information provided by this technique is insufficient to diagnose some of the complex physiopathological processes that characterize traumatic brain lesions. Consequently, the use of methods to estimate cerebral blood flow such as transcranial Doppler and jugular oximetry to complement ICP monitoring is becoming increasingly widespread. Nevertheless, determining the effect of tissue lesions and therapeutic measures on cerebral metabolism currently requires direct access to the brain parenchyma at the bedside. In this review we focus on three methods of regional cerebral monitoring: oxygen tissue pressure (PtiO(2)) monitoring, microdialysis and near-infrared spectroscopy. The bases of each method and reference values for the variables analyzed will be discussed. We also make a series of recommendations on how results should be interpreted in light of current knowledge.

[Global systems for monitoring cerebral hemodynamics in the neurocritical patient: basic concepts, controversies and recent advances in measuring jugular bulb oxygenation]. / Métodos globales de monitorización de la hemodinámica cerebral en el paciente neuricrítico: fundamentos, controversias y actualizaciones en las técnicas de oximetría yugular

Because of the importance of hypoxic/ischemic phenomena in head-injured patients, brain monitoring in these patients should be complemented by systems providing information on cerebral blood flow and metabolism. Indirect estimations of cerebral blood flow have been obtained from blood extracted from the jugular bulb, as a special bedside application of the Fick's principle to the brain. In the last few years, the use of jugular oximetry techniques has become routine in centers treating head-injured and other neurocritical patients such as those presenting subarachnoid hemorrhage or malignant middle cerebral artery infarction. The experience acquired in the use of these techniques, as well as the introduction of new neuromonitoring systems, have deepened our understanding of the information gained and have enabled more precise definition of their indications and limitations. This review describes the basic concepts underlying the use of jugular oximetry techniques in the neurocritical patient. We also explain the reasons why several variables derived from jugular blood such as arterio-jugular differences of lactate (AVDL) or the lactate-oxygen index (LOI) do not provide accurate information on brain metabolism.

[Variability in the surgical indications for posttraumatic intradural lesions]. / Variabilidad en las indicaciones quirúrgicas de las lesiones intradurales postraumáticas.

INTRODUCTION: The surgical treatment of focal intradural lesions is still a matter of considerable debate. This is especially important in the decision to evacuate brain contusions. We present the results of a prospective observational study in which the main goal was to analyze intracenter variability in the indication for surgery in focal posttraumatic intradural lesions in a department of Neurosurgery of a University Hospital with a specialized neurotrauma unit. CLINICAL MATERIAL AND METHODS: Between May 1 and December 31, 2001, 32 patients with a closed traumatic brain injury and an intradural posttraumatic focal lesion were included. The patients studied were a subgroup included in the European multicenter observational study of the management of intradural lesions conducted under the aegis of the European Brain Injury Consortium (EBIC). RESULTS: Intradural lesions > 25 cc were immediately evacuated. Nine out of thirteen patients with lesions < 25 cc also underwent surgery due to intracranial hypertension or neuroworsening. In all patients in whom lesions were surgically evacuated, the postoperative CT-scan showed neuroradiological improvement of the signs of mass effect or midline shift. CONCLUSIONS: In our center, we found no evidence of significant variability in the indications for surgery in intradural lesions of more than 25 cc. However, significant differences were detected among neurosurgeons in the surgical indications for lesions below 25 cc. The small sample analyzed precludes generalization of these conclusions. The definitive results of the EBIC study will provide the neurosurgical community with a better understanding of variability in the management of these lesions.

Moderate hypothermia in the management of severe traumatic brain injury: a good idea proved ineffective?

Many drugs with proven efficacy in the preclinical stage have failed to show any benefit in improving the outcome of severe traumatic brain injury (TBI) when tested in controlled clinical trials. Hypothermia is still the most powerful neuroprotective method in experimental models of TBI. Its ability to influence the multiple biochemical cascades that are set in motion after TBI is quite unique. In experimental models hypothermia protects against mechanical neuronal and axonal injury and improves behavioral outcome. Encouraging results from phase II and III clinical trials of hypothermia in TBI reported in the 1990s generated great enthusiasm. However, enthusiasm faded in 2001 after the final report of the multicenter phase III trial in which the neuroprotective effects of moderate hypothermia in TBI were formally tested. This study found no significant effect on outcome in the hypothermia group, leading many clinicians to lose interest in this therapy. The present article reviews the historical background of the use of hypothermia, presents the rationale for using both immediate and deferred hypothermia, and summarizes both experimental and clinical evidence supporting its potential benefits in the management of severe TBI. New technologies using intravascular methods to induce fast hypothermia have recently become available. Cooling either through the intravenous or intra-arterial route is an exciting alternative with great potential. We argue that moderate hypothermia is still the most powerful neuroprotective candidate for severe TBI and that it merits further research and discussion. We also defend the need for further clinical trials to prove or refute its potential for treating high intracranial pressure refractory to first level therapeutic measures. The premature abandonment of hypothermia could close new avenues for improving the devastating effects of TBI.

[Use of teleradiology in the evaluation and management of head-injured patients. Results of a pilot study of a link between a district general hospital and a neurosurgical referral center]. / Aplicaciones de la telerradiología al cribaje y manejo de los pacientes con un traumatismo craneoencefálico. Resultados de un estuduo piloto de interconexión entre un hospital comarcal y un centro de referencia neuroquirúrgico.

UNLABELLED: Because of the centralization of neurosurgical services, many head-injured patients who are initially evaluated in district general hospitals need to be transferred to a high technology centre for neurosurgical assessment. However, after assessment, many of these patients are sent back to the original hospital. Establishing a teleradiological system between the two hospitals would eliminate these unnecessary transfers. OBJECTIVES: 1) to describe our initial experience and the results of a pilot study of the teleradiological link between a district general hospital and a tertiary hospital for neurosurgical assessment of head-injured patients, 2) to describe the infrastructure and the technological support required for this project, 3) to analyse the effects of the teleradiological link in both centers (referring and receiving), 4) to evaluate the effectiveness of the system in avoiding unnecessary transfers, and 5) to assess its effectiveness in improving the speed and the quality of transfers in head-injured patients. MATERIAL AND METHODS: In January 1998, the Neurotraumatology Unit of Vall d'Hebron University Hospital established a teleradiological link with the General Hospital of Vic for the neurosurgical evaluation of headinjured patients. The General Hospital of Vic sent the patients' clinical information by fax. CT scan images were digitalized, compressed and prepared for transmission with the StatView program, and were then transmitted by modem to the receiving center. The duty neurosurgeon viewed the images on a PC screen using MutiView software. After evaluating this clinical and radiological information the neurosurgeon sent a report back to the referring center recommending transfer or management (admission, observation, etc.). RESULTS: We analyse the results of our experience 5 years after the implantation of the teleradiological link. CONCLUSIONS: The use of teleradiology in the daily management of head-injured patients provides clear benefits and leads to a more rational use of resources, thus significantly reduces costs. The effectiveness of the system in reducing the interval between the injury and treatment in severe cases depends more on the infrastructure of the health system in each geographical area than on sophisticated telemedicine systems. These methods should be accompanied by other measures designed to hasten the transfer of selected patients.

[Value of brain perfusion SPECT in the follow-up of patients surgically treated for chronic adult hydrocephalus syndrome]. / Valor del SPECT de perfusión cerebral en el seguimiento del tratamiento quirúrgico de pacientes con hidrocefalia crónica del adulto.

OBJECTIVE: The aim of this study was to characterize regional cerebral blood flow in patients with Adult Hydrocephalus Syndrome (AHS) and to evaluate the changes in brain perfusion after surgical derivation treatment. PATIENTS AND METHODS: 20 patients with AHS (age: 72 +/- 14, 12 men) were studied before and six months after surgery. All patients underwent a brain perfusion SPECT (99mTc-HMPAO) prior to surgery and at 6 months post-surgery. Semi-quantitative analysis was done for brain uptake: 0=Normal, 1=Mild, 2=Moderate, 3= Severe, 4=No uptake. The severity of ventricular dilatation was assessed by classifying the intensity and extension of subcortical defects: 0=Normal, 1=Mild, 2=Moderate, 3=Severe. The scores of the pre- and post-surgical studies were compared using the Student-t test. RESULTS: A global reduction of brain uptake was observed (mean score 12.85), mainly in frontal, parietal and temporal lobes, with a significant improvement in post surgical studies (mean score 6, p<0,001). After surgery, 16 (80%) of the 20 patients improved brain uptake. In relationship to subcortical uptake, 5 patients showed mild defects, 9 moderate defects and 6 patients presented severe uptake reduction. In post-surgical studies 15 (75%) patients improved almost one degree in the subcortical score and 65% of the patients showed a normal or mild subcortical uptake reduction. CONCLUSIONS: Brain perfusion SPECT is useful in patients with AHS, detecting brain perfusion defects and evaluating cerebral blood flow improvement after shunt operation.